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From the moment I started using this product my symptoms slowly started to disappear day by day until I was back to normal again. High blood sugar levels in the body due to the infectious challenge, because it lost more than its capacity. Appropriate treatment and timely, balanced diet The Diabetes Cure Program and regular exercise with diabetes a natural, healthy and happy life can enjoy. Basically, every cell in the human body from glucose and serve as an important source of energy. Cell-based therapies offer a novel treatment strategy to augment diabetic wound healing, increase ulcer healing rate and prevent amputation. In the presence of diabetes, no one has ever been able to confront chronic medical conditions is one of the most feared. The field of tissue engineering has developed commercially available skin substitutes for diabetic cutaneous wound repair. Adequate supply of insulin to the body, when glucose is usually produces diabetes, not to be broken. A chronic disease is referred to as, and as the kidney or renal failure, and a variety of heart and cardiovascular disease, blindness, and vascular disease, nerve damage, paralysis, medical The Diabetes Cure Diet and health also lead to serious complications, and appropriate medical care is not provided if the diabetes burden could be . However, having been available for the last decade, the majority have demonstrated only moderate clinical benefit in small clinical trials. In comparison, stem and progenitor cell therapy offer the potential for accelerated wound repair in addition to structural skin regeneration with functional recovery. Stem cells have the ability to self-renew and differentiate into other cell types and are classified into adult stem and progenitor cells, embryonic stem cells and induced pluripotent stem cells.
The mechanisms of action of stem and progenitor cells are not fully elucidated but include 1) differentiation to specialised cells e.g. Much research endeavour is determining the benefit of stem cell treatment on diabetic cutaneous wound healing with encouraging results in animal models. Regenerative medicine and tissue engineering specialties are rapidly elucidating the mechanisms of action of stem cells and translating the results of in-vitro and in-vivo experiments to human clinical trials. The requirements for success will be patient safety, clinical efficacy and convenience of use.The focus of this chapter is to review the area of topical stem and progenitor cell therapy as a treatment for non-healing diabetic foot ulcers. It will focus on adult stem cells as these are nearer to use in human trials and do not pose the ethical constraints associated with the use of embryonic stem cells.
Topical treatment with endothelial progenitor cell (EPC) and mesenchymal stem cell (MSC) therapy is presented in this review, and more specifically the delivery of these cells using biomaterial scaffolds. The case for adopting stem and progenitor cell therapy in research and treatment of diabetic foot ulcers will be discussed.
The benefits of biomaterials and functionalised scaffolds for mediating cell therapy to a wound will be described.
For both endothelial progenitor cells and mesenchymal stem cells, the potential mechanisms of action will be discussed with reference to key pre-clinical and clinical studies.
The chapter will also describe strategies to enhance the therapeutic potential of stem and progenitor cells for wound healing. A section of the chapter will focus on translational of these advanced biological medicines to clinical trials. This includes issues regarding pre-clinical animal models, optimal cell source, safety and regulatory approval. The biology of cutaneous woundsThe repair of cutaneous wounds is a highly complex biological process. The goal of adult wound healing is to repair a skin defect, to ensure the restoration of a barrier and to regain tensile strength. There is involvement of several cell types, cytokines and extra-cellular matrix components.
The physiological overlapping pathways that are required for optimal wound healing include haemostasis (which occurs immediately on wounding), inflammation with cell migration and proliferation (neutrophils initially and subsequently macrophages).
Angiogenesis (growth of new blood vessels from pre-existing blood vessels) and re-epithelialisation are central processes in wound healing. This is a superficial description of wound healing and conveys the complexity of the process, but highlights the potential for disruption in a difficult to heal wound. Diabetic wound healingDelayed wound healing as occurs in diabetes mellitus results from dysregulation of the normal healings pathways. The diabetic wound is complex with contribution from infection, neuropathy and impaired vascular supply. These include decreased or impaired growth factor production, angiogenic response, macrophage function, collagen accumulation, epidermal barrier function, quantity of granulation tissue, keratinocyte, fibroblast migration and proliferation and bone healing.
There is an imbalance between the accumulation of extra-cellular matrix components and their re-modeling by matrix metallo-proteinases.(Brem et al.
Angiogenesis and wound HealingThe impaired vascular supply associated with diabetes leads to poor blood flow at the wound site impeding the optimal endogenous reparative response (Jeffcoate & Harding 2003) Impaired angiogenesis is a feature of diabetic wounds. In addition neovascularisation, or the de novo formation of new blood vessels is critical for granulation tissue formation and tissue regeneration in wound healing. In the non-diabetic situation, hypoxia leads to activation of the transcription factor complex HIF-1? (Hypoxia inducible factor-1?), which leads to transcription of multiple genes required for successful wound healing.
Skin regeneration is the regeneration of wounds with restoration of the normal function and anatomy of skin.
In biology, foetal wound repair is a regenerative process, and some vertebrate species demonstrate successful tissue regeneration where the initial phase of wound repair is followed by perfect structural and functional regeneration of the organ. The challenge for scientists is to produce tissue engineered products that exhibit extra-cellular matrix re-modeling characteristics seen in embryonic wound repair to produce functional and durable skin. Classification of diabetic ulcersDiabetic foot ulcers can be classified as ischaemic, neuropathic or neuro-ischaemic. The typical angiographic pattern of ischaemic diabetic vasculopathy is occluded distal blood vessels.
Ulceration develops at sites of excessive pressure predominantly under the first metatarsalphalangeal joint, in the majority due to unperceived trauma. Current treatment strategiesThe management of the diabetic foot is complex requiring a multidisciplinary approach. Benefit of a cell-based therapy for non-healing diabetic ulcersIt is evident that there is a critical clinical need to develop novel therapies for treatment of non-healing diabetic ulcers in order to prevent amputation and reduce the significant financial drain on healthcare budgets and burden on individuals health.
The understanding of the patho-physiology of diabetic wound healing is important in the development of advanced wound healing treatments. Cell therapy may reverse the biological defects in diabetic wounds by acting as reservoirs for cell and growth factor production.
Limitations with current cell-based therapyTo date clinical trials of topical cell based therapy for non-healing diabetic foot ulcers have yielded limited results.


One reason is methodological flaws in the clinical trials which have raised concerns over the validity of the results. Systematic reviews on skin replacement therapy have reported statistical benefit in wound healing endpoints. However there was a lack of information reported on safety, method of recruitment, randomization methods and blinding strategy for outcome assessments.
There is a lack of power size calculations in some of the trials and little mention of dropouts in trial.
The current somatic cell therapies do not address the underlying pathology in the diabetic wound i.e. An efficient blood supply is central to normal wound healing, and delayed or inefficient angiogenesis will prolong ulceration and increase the probability of amputation.
The current cell treatments do not target angiogenesis (blood vessel formation from pre-existing blood vessels) or neo-vasculogenesis (de novo blood vessel formation).
The employment of these cell treatments result in wound healing by repair and not by regeneration. Potential superiority of treatment with stem and progenitor cellsEndothelial progenitor cells are a newly described cell type involved in angiogenesis. Adult mesenchymal stem cell treatment holds promise as this cell type addresses the key wound impairments seen in non-healing diabetic ulcers. They are immuno-modulatory and may create a more favourable inflammatory environment of the diabetic wound. Adult mesenchymal stem cells in diabetic wounds may in addition to beneficial paracrine activity, differentiate into other cell types e.g.
BackgroundThe discovery of putative EPCs by Ashara et al in 1997 (Asahara, et al., 1997) has illuminated the fields of vascular biology and diabetes related vascular dysfunction. For the first time, vasculogenesis or de novo blood vessel formation was determined to occur post-natally, as previously it was assumed to occur only during embryogenesis.
The delivery of EPCs to ischaemic sites in the body offers the possibility of successful treatment of diabetic vascular disease. Worldwide, research groups are testing the hypothesis that EPC therapy may treat peripheral vascular disease and prevent the progression of non-healing diabetic foot ulcers to amputation.
These cells are suitable for autologous therapy without immunological rejection but this approach may be hindered due to disease associated cell dysfunction.EPC research is complicated by several issues. The reports in the literature describe different identities, sources of isolation, culture methodologies and function.
The first cell type is named colony forming unit-Hill cells which arise from peripheral blood mononuclear cells which are non-adherent and give rise to a colony after 5 days in culture. The second cell type is a heterogenous collection of cells termed circulating angiogenic cells or early EPCs. These arise from mononuclear cells which are adherent to fibronectin or other matrix adhesion proteins after 4-7 days. These cells are derived from mononuclear cells that adhere to fibronectin and appear after 6-21 days.
The different cell types may also be characterized by flow cytometry for surface immunophenotype. The mechanism is reported as via paracrine effect, direct incorporation in blood vessels and differentiation into endothelial cells. The field of topical EPC therapy is in the early stages with benefit demonstrated in these studies. In addition the standardisation of cell dose, definition of cell type and animal model is required. The use of human cells in immunocompromised animals are required to further elucidate therapeutic efficacy 4.3.
Paracrine effectEarly EPCs and Late EPCs may contribute to post-natal neovascularisation by secretion of angiogenic cytokines and growth factors.
The secretome of EPCs contains cytokines and growth factors which stimulate wound healing by increasing proliferation, migration and cell survival of the different cell types required for wound healing i.e. Direct incorporation in blood vesselsThe second mechanism of action is the direct incorporation of EPCs into the growing blood vessel wall or the differentiation of these cells into mature endothelial cells.
This mechanism is associated with late EPCs This mechanism has been shown in animal models and may not be as significant as the paracrine effect of cell therapy. The transplantation of conditioned media or identified therapeutic factors would allow for protein-based therapy. One study compared conditioned media from EPCs to EPC treatment alone in an animal model of cutaneous wound healing. Impaired angiogenesis in diabetes due to EPC dysfunctionIt is known that EPCs are decreased in number and dysfunctional in people suffering from diabetes mellitus. This is due to decreased mobilisation from the bone marrow and decreased homing to cutaneous wounds.
Topical delivery In normal healing EPCs are released into the circulation from the bone marrow in response to ischaemia and travel to sites of tissue injury and participate in angiogenesis. In mice with cutaneous wounds and 4 weeks of streptozocin induced hyperglycaemia, the levels of circulating EPCs were unchanged but the levels of bone marrow derived EPCs within the wound granulation tissue were decreased as compared to non-diabetic controls. The bone marrow derived EPCs from diabetic mice showed increased apoptosis and decreased proliferation in diabetic wound tissue as compared to non-diabetic controls. This ex-vivo manipulation may restore the EPC functional defect and succeed in restoring diabetic wound healing to the non-diabetic phenotype. Systemic delivery of stem cell results in cells being taken from the circulation in the lungs, spleen and liver and not reaching the wound. The topical delivery of cells allows for concentrated doses of cells to be delivered to a skin wound and not become trapped in other sites in the body.
Matricellular proteins: Osteopontin Osteopontin (OPN) is a matricellular protein and is involved in tissue repair and angiogenesis. These proteins modulate cell function by interacting with cell-surface receptors, proteases, hormones, and other bioeffector molecules, as well as with structural matrix proteins such as collagens (Bornstein, 2009) Decreased OPN is found in EPCs in diabetes mellitus. Osteopontin knockout mice have decreased myocardial angiogenesis in response to ischaemia and delayed recovery after hindlimb ischaemia.
Wound healing studies in osteopontin knockout mice show more residual debris and less matrix organisation than wildtype mice. Delay in diabetic wound healing may arise in part because of the low expression of OPN early in the wound bed after wounding, resulting in the reduced migration of immune cells to the site of injury leading to the accumulation of cell debris, decreased recruitment of endothelial cells, delayed angiogenesis and poor matrix organization. Current delivery options include injection of cells, delivery in extra-cellular matrix, delivery on a scaffold and delivery as part of a tissue engineering skin equivalents. The vascular progenitor cells exit the biomaterial over time and repopulate damaged tissue and participate in the vascular network. Co-culture, gene therapy and hyperoxia It is hypothesised that endothelial progenitor cells act as angiogenic support cells by their paracrine activity. Co-administration of EPCs with smooth muscle progenitor cells increased vessel density in a mouse model of hind-limb ischaemia to a greater degree than administration of either cell alone. Using an ex vivo gene transfer strategy, EPC cell cultures can serve as gene carriers and function as a temporal local production unit of de novo synthesized growth factors within the wound or skin replacement.
Increase number of EPCsIncreasing EPC number for topical treatment increases the wound healing benefit of EPCs. In-vitro animal studies reveal that proliferation of EPCs derived from the bone marrow can be accelerated by GM-CSF. It has been used in human clinical trials for investigation of autologous therapy in critical limb ischaemia.



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